Get the best benefit by visiting doctors, hospitals, and other providers contracted in your network. Otherwise, you could be on the hook for unnecessary large bills.
Find in-network doctors, hospitals, and clinics at PEHP for Members (click “Find and Select a Provider” under the “my Benefits” menu).
Take care to avoid these common pitfalls:
» Be sure to verify with the provider. The Provider Lookup may change at any time. Verify directly with providers they are contracted in your network. Providers may be contracted with PEHP, but not in your specific network (e.g., Summit, Advantage); be sure to verify. Show your PEHP ID card before you receive services to be sure.
» Make sure every person and every facility involved in your care is contracted in your network. For example, just because your doctor is in your network, don’t assume the lab he/she uses is too. Be sure to verify. If you get medical equipment – such as a brace or sling – at the doctor’s office or hospital, it will likely be billed by a different provider. Make sure that provider is contracted in your network. If your doctor refers you elsewhere for services? Always verify.
You may get a huge, unexpected bill. That’s because PEHP has no pricing agreement with out-of-network providers. We have no say in what they charge. Even if your plan pays benefits for out-of-network providers, they’re based on the in-network rate. If the out-of-network provider charges more than the in-network rate, you will be billed for the full amount of the difference (this is called balance billing).
PEHP pays benefits for out-of-network emergency room visits up to the in-network rate that we’d pay an in-network ER. However, an out-of-network ER may charge more than the in-network rate (remember, PEHP has no pricing agreement with providers outside of your network). The provider may bill you the difference between the in-network rate and the billed amount (balance billing). Note the nearest in-network hospital to your home, work, and school to reduce your chances facing large, unnecessary bills.
At PEHP, we want to help you navigate healthcare to get the most from your benefits. These two brief brochures can help you understand your benefits and avoid costly bills.